Patient Prostate Self-Evaluation

Patient Name: ________________________________________

Date: ___/___/___

Q1: Over the last month or so, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?

1. None
2. 1 time
3. 2 times
4. 3 times
5. 4 times
6. 5+ times

Q2: Over the last month or so, how often have you had a sensation of not emptying your bladder completely after you finished urinating?

1. Not at all
2. Less than 1 time in 5
3. Less than half the time
4. About half the time
5. More than half the time
6. Almost always

Q3: Over the past month or so, how often have you had to urinate again less than two hours after you finished urinating?

1. Not at all
2. Less than 1 time in 5
3. Less than half the time
4. About half the time
5. More than half the time
6. Almost always

Q4: Over the past month or so, how often have you found that you stopped and started again several times when you urinate?

1. Not at all
2. Less than 1 time in 5
3. Less than half the time
4. About half the time
5. More than half the time
6. Almost always

Q5: Over the past month or so, how often have you found it difficult to postpone urination?

1. Not at all
2. Less than 1 time in 5
3. Less than half the time
4. About half the time
5. More than half the time
6. Almost always

Q6: Over the past month or so, how often have you had a weak urinary stream?

1. Not at all
2. Less than 1 time in 5
3. Less than half the time
4. About half the time
5. More than half the time
6. Almost always

Q7: Over the past month or so, how often have you had to push or strain to begin urination?

1. Not at all
2. Less than 1 time in 5
3. Less than half the time
4. About half the time
5. More than half the time
6. Almost always

Total the results for questions 1 to 7 = _____

Scoring:

Coming tomorrow.

From the American Urological Association (AUA) Symptom Index for BPH.

Revised February 9th, 2006